Because pain has so many causes and treatments, one of the best ways to sharpen your pain-management skills is to study how your colleagues successfully handle particularly challenging patients. Here are two case histories of such patients — involving the knees, back and wrist — from two practitioners who are also pain experts.

Case 1: Alternatives to NSAIDs for knee pain

By Yvonne D’Arcy, MS, CRNP, CNS

Mrs. C, 65 years old, presented with complaints of increasing pain in both knees. She described the pain as moderate-to-severe and mentioned that it has made sleeping difficult and limited her walking ability to the point where she can no longer climb stairs. Methyl salicylate/menthol (Bengay) and other topical creams provided no relief. Mrs. C had been taking a nonsteroidal anti-inflammatory drug (NSAID) for pain, but she wanted to find an alternative.

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Medical history

Mrs. C was diagnosed with osteoarthritis five years before. She has diabetes that is controlled with oral medication. Obese, she had twice been referred to weight-loss programs by her diabetes educator, with little success, although she was compliant with her drug regimen. An allergy to eggs caused severe urticarial wheals. In addition to ibuprofen 400 mg four times daily, she was taking a proton pump inhibitor (PPI) for GI prophylaxis.


Using a cane for assistance, Mrs. C moved slowly into the exam room, then she used her arms to help lift her body up onto the table. Vital signs were normal. At 5 ft 6 in, she weighed 210 lb. Glucose was 135 mg/dL. Inspection of her knees revealed moderate swelling and warmth. Bilateral crepitus was heard in both knees. Deep tendon reflexes were normal. Flexion and extension were reduced in both knees, and Mrs. C complained of moderate pain when her knees were manually manipulated. 

Because there was no significant fluid collection, aspiration was unnecessary. MRI revealed significant bilateral joint-space narrowing. Osteophytes were seen on patellar surfaces, and the cartilage on several areas had eroded. A complete blood count and metabolic panel were ordered to test for NSAID-induced anemia or liver dysfunction. All results were within normal limits.

Treatment plan

While it would have been easy to simply refer Mrs. C back to her orthopedist, she had significant medical- and pain-management needs that required immediate intervention. In addition, Mrs. C did not like her NSAID, and extended use increases the risk for stroke, heart attack and GI bleeding. Even with the use of a PPI, stopping the NSAID would be a good decision. 

Mrs. C mentioned that she had been unable to follow any previous weight-reduction programs and that physical activity was difficult with her current knee pain. However, patients with osteoarthritis can benefit significantly from losing 20 lbs. The reduced load on the joints can decrease pain and increase function.

Mrs. C was referred to a weight-reduction program that also focused on strengthening her quadriceps muscles through physical therapy. Stronger quadriceps allow for easier ambulation and pain reduction. After each therapy session, Mrs. C was advised to apply cold packs and iontophoresis.

Iontophoresis uses a mild electrical current to deliver topically applied anti-inflammatory agents directly to the site of the pain, while cold packs help reduce swelling. Referral was also made to a psychologist, with whom Mrs. C could discuss her weight-loss attempts and learn how to avoid the pitfalls that made her previous attempts fail. 

Because Mrs. C complained of pain, she was provided with a transcutaneous electrical nerve stimulator (TENS) unit. This would allow her to control her pain between physical therapy sessions. Although the research on TENS with osteoarthritis is not conclusive, there is enough evidence to suggest that pain reduction is one benefit. 

During her initial evaluation, Mrs. C stated that she did not like the idea of having needles inserted into her knees, but an NIH study, has shown that acupuncture increases function and decreases pain in patients with arthritis. Mrs. C agreed to an initial informational meeting with the acupuncturist at the physical therapy center. 

Last, Mrs. C was prescribed lidocaine (Lidoderm) 5% gel patches, up to three patches daily. The patches can be applied to the knees for periods of 12 hours on, 12 hours off, with no systemic uptake. Because the pain was worse at night, she was told to use the patches whenever she had trouble sleeping. 

Mrs. C is allergic to eggs, so she should not be given hyaluronate (Hyalgan) injections. Although such injections may significantly decrease pain, Hyalgan is made from the combs of roosters and should be avoided by those with egg allergies. Use of glucosamine chondroitin should also be avoided. Mrs. C is diabetic, and studies suggest that glucosamine can increase insulin resistance.


At six weeks follow-up, Mrs. C was no longer using a cane and her pain had diminished. She had been meeting three times a week with a physical therapist to work on her leg strength, and she has noted a difference in how she walks.

Her meetings with the psychologist revealed that her biggest downfall when it came to losing weight was the tendency to eat at night and between meals. Avoiding this has resulted in a weight loss of 10 lb. Her blood sugar levels have also improved. While she tried acupuncture, she felt it did not work well for her. She does, however, like the TENS unit and Lidoderm patches. 

Overall, Mrs. C was happy with the pain relief she was getting. She rated her pain at 3/10, although she did note that sleep is still difficult at times. She was advised to listen to relaxation tapes during the evening. Although she has never used them, Mrs. C is open to trying them and planned to discuss their efficacy with her psychologist.

Yvonne D’Arcy, MS, CRNP, CNS is the pain and palliative care nurse practitioner and outcomes manager for Suburban Hospital in Bethesda, Md.